Champagne, Patricia frClq
NEW YORK STATE DEPARTMENT OF HEALTH
. . r B i a. - Transit Permit
Vital Records Section u r
AV Name First 0 k Middle Last Sex
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1§1
Date qf Death Age If Veteran of U.S. Armed F cers,
ts_g 1.z2 )13 War or Dates
A Place of Death Hospital, Institution or ses_r_cAr. c ,u6__sti W_
City, Town or Village Sc,c-c.--L. e. S7 Street Address
1 Manner of Deathyej Natural Cause El Accident El Homicide p Suicide El Undetermined n Pending
f ' Circumstances "—'Investigation
r Title Medical Certifier Name \ n c...)
,
II Address ,.),...
SARATOGA SPRINGS
ig Death Certificate Filed District Number 1 F; ister Number
II City, Town or Village q 5°1 RSD
...E;i ,Burial Date a a_c_ ii 3 Cemeterwr Crematory
LJ ),(.1z._ ki%-c_t...-,..)
21
Address 7i,Cremation kt, ragoLt
Date Place Removed
2 ri Removal and/or Held
g Li and/or Address
Hold
9 Date Point of
is 0 Transportation Shipment
5 by Common Destination
::.:. Carrier
El Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
1 Permit Issued to Registration Number
Name of Funeral Home PDeykSvv.10.rt._ Tt.,k."..ex-c-k
--IM Address ---1
S -w-Nc_—__ 4.--v,e C_o r r\-V q•-( \g_g ap--
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0 Name of Funeral Firm Making Disposition or to Whom
tom Remains are Shipped, If Other than Above
'AA Address
IC
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Ail
ilo Permission i_szh rebygoranted to dispose of the human remai ri d abo e as indicated.
Date Issued ' 03 Registrar of Vital Statistics - —4711.41.4v.pk
0
aci ' ignliihl SARATOG p s
iw District Number 9 5-01 Place
AF,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition z-t-1-V3 Place of Disposition ZAN) cr4,-cHorsvp....
2 (address)
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(section)g -(lilt.Lnumper) (grave number)Name of Sexton or Person in Cherie of Premises dr2)AtI r 30.1..4
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Z (please print)
LO Signature IlL a- Title CREVIPIOP
(over)
DOH-1555 (9/98)
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